In 2017, more than 2.7 million people died in the United States. What happened to their bodies after they died? They were cared for by workers in America’s death care industry—those employed by funeral homes, cemeteries, and crematoria. Death care workers weren’t always employees. Historically, families would care for their deceased loved ones: the family would wash, clothe, casket, and hold a wake for their deceased. After the wake, the body would be buried at a local church or in a family graveyard a few days after the person died. However, during the Civil War there emerged a new profession—undertakers, now called morticians, undertook the transport and preservation of the dead. Many of the deceased were young men who had died far from home whose grieving families wanted to see them one last time before they were buried—which was only possible with the miracle of modern embalming.  More than 150 years after the Civil War, embalming is still a common practice in America. In our culture, a body that will be viewed will usually be embalmed, regardless of whether the body will be buried or cremated. Embalming involves chemically treating the body to prevent microbial growth and stall decomposition, as well as restoring a lifelike appearance. Embalming’s popularity has been maintained by many forces, and one is the myth that dead bodies are inherently dangerous. While there are some diseases that can be transmitted post-mortem (tuberculosis and Ebola, for example), for the most part the lowered temperature in a corpse makes the body less hospitable to many infectious agents. Corpses typically pose less danger than do living human beings.  There are two common embalming procedures: arterial and cavity embalming. In arterial embalming, fluid is put into a centrifugal pump, which acts like the heart, pumping fluid into the arteries and out of the veins, displacing the blood that is there. Embalmers typically pump fluid into the right common carotid artery and out of the jugular vein or the right femoral vein. The displaced body fluids and embalming fluid are poured down the drain. The process is different with a corpse that has been autopsied or suffered physical trauma as the closed circulatory system may be compromised, necessitating suturing.  Compared with arterial embalming, cavity embalming is a bit violent and is technically considered legal corpse mutilation. The goal of cavity embalming is to remove the contents of the torso so that the internal organs don’t begin to putrefy. To prevent this, the embalmer punctures the abdomen with a hollow-bore needle called a trocar, whereupon the liquid contents of the cavity are aspirated and replaced with embalming fluid. The hole left by the trocar is closed up with a “trocar button.” As with arterial embalming, cavity embalming differs if the body was autopsied. Typically, the internal organs are embalmed in a bucket outside of the body and then replaced after embalming is complete.  Embalming fluids are complex mixtures that contain preservatives, germicides, anticoagulants, perfuming materials, surfactants, and dyes. Typical components of embalming fluids are formaldehyde, methanol, phenol, ethylene glycol, glyoxal, and glycerin. Much like a secret family recipe, many embalmers have their own unique blend of chemicals they prefer for embalming services. Of these, formaldehyde, or FA, is both a common and hazardous ingredient. A 37 percent (by weight) FA solution is known as formalin and has been a fixture in embalming fluids since the late 1800s. Ten percent methanol is typically added to formalin to prevent the precipitation of paraformaldehyde. FA is a respiratory and skin sensitizer, irritates the eyes and respiratory system, and increases the risk of nasopharyngeal cancer, as well as leukemia. Absorption can occur via inhalation, ingestion, and the dermal route.  While the health risks of FA are well known in the death care industry, embalmers tend to prefer FA-based embalming solutions as they are cheap, fast-acting, and familiar. The European Union recently proposed a reduction in occupational exposure limits for FA (0.3 ppm as an eight-hour time-weighted average and a short-term exposure limit of 0.6 ppm), and there is some concern among European embalmers that FA will be banned by the Biocidal Products Directive 98/8/EC as it’s been classified as a carcinogen; if this occurs, non-FA options may become more widespread in Europe. Previous efforts have been made to steer the industry toward other preservatives such as glutaraldehyde, a higher molecular weight aldehyde that does not appear to be a carcinogen. However, glutaraldehyde is more expensive, slower-acting than FA, and has its own health concerns, such as respiratory and skin sensitization.

Cremation is practiced widely throughout the world with some countries, such as Japan, that almost exclusively cremate their deceased. Cremation is growing in popularity in America with 2018 being the first year in which more Americans chose cremation over traditional burial. However, it is important to note that an increase in cremation rates does not necessarily imply a decrease in rates of embalming; if a body is viewed before cremation, it typically will have been embalmed.  Cremation consumes the organic material of a corpse via flame until it is reduced to calcified bone. An incinerator is preheated to about 1,100 F (593 C), mechanized doors are opened, and a simple container holding the body moves on a rack of rolling metal pins into the primary cremating chamber called the retort. Once the door is sealed, the body is subjected to a jet-engine-like column of flame, aimed at the torso. The heat ignites the container and dries the body, which is composed of 75 percent water. The body is consumed first at the skin, followed by the muscle and viscera. Finally the bones calcify as they are exposed to the heat and begin to flake or crumble. An average human body takes two to three hours to burn completely and will produce an average of three to nine pounds (1.4 to 4.1 kilograms) of remains. The amount of remains depends on the deceased’s bone structure rather than weight. After the retort, the remains are put in a machine called a cremulator that pulverizes the bones into homogenous kitty litter-like material. While crematory operators are not exposed to the same variety of chemical hazards as embalmers, they may be exposed to silica dust when raking out remains from the retort, as it is lined with refractory bricks. In addition to quartz, refractory bricks have been found to contain cristobalite after exposure to high temperatures. Crematory repair workers may also be exposed to silica during the relining of the refractory brick inside the retort. Crematory operators are also routinely exposed to physical hazards such as heat, noise, and awkward postures.  There are additional environmental concerns with cremation, including the burning of fossil fuels to heat the retort and emissions from the incineration of corpses themselves, which have been found to contain dioxins and mercury.  Whether a body is buried or cremated, death care workers are likely to contend with ergonomic hazards when handling bodies in transport to the funeral home, in cold storage (where bodies are kept prior to embalming or cremation), during embalming, before cremation, and during burial. While lifts, hoists, and body carts are available to prevent awkward postures and overexertion in mortuary facilities, death care transportation workers frequently retrieve corpses from homes or apartments without lift devices. This task can be especially daunting if the recently deceased was large or the person died in a place that is difficult to access. There is also a cultural emphasis on dignity in death, so many death care workers won’t use engineering controls in front of grieving loved ones.  Embalmers also contend with ergonomic risk factors; they may adopt awkward postures at embalming tables (although some height-adjustable embalming tables are available, not all of them have integrated ventilation). In addition, embalmers massage corpses to relieve rigor mortis, which can subject them to repetitive strain injuries.   While OSHA and most state plans don’t enforce ergonomic regulations, they do have the power to address many of the occupational health risks found in the death care industry. A look at historical compliance data in the state of Washington revealed that the State OSHA Program (the Division of Occupational Safety and Health, or DOSH) conducted 80 industrial hygiene inspections of the death care industry from 1997 to 2007. The five most common violations included no written safety program, no safety meetings, no chemical hazard communication training, no bloodborne pathogens exposure control plan, and no FA exposure evaluation. DOSH Compliance conducted 10 industrial hygiene sampling events for FA in funeral homes during the years 1997–2017, resulting in one citation for overexposure. Six of 10 sampling events showed exposures above ACGIH’s TLV or ceiling.  Enforcement efforts may change as our society starts to integrate newer death care approaches. Current emphasis on the environmental impact of traditional interment methods is leading to an interest in non-traditional methods such as alkaline hydrolysis, also known as “aquamation,” and green burial. Where cremation consumes organics via flame, “aquamation” consumes organics via water in the form of a basic solution. The alkaline hydrolysis process has been championed as “green cremation” for using one-quarter the energy of flame-based cremation and producing less carbon dioxide and fewer pollutants. Alkaline hydrolysis mimics natural decomposition; in the aquamation chamber, conditions are ideal for this process, which results in rapid decay. The chamber is a pressure vessel that is filled with a mixture of water and caustic (typically soda ash or caustic soda pearls) and is heated to a temperature around 320 F (160 C). Due to the caustic, the chamber contents are quite basic, with a pH of about 14. Depending on the length of the cycle (typically four to six hours) and the amount of fat in the body, the pH will vary, but will eventually tend toward neutral. The waste generated by aquamation is a greenish liquid that contains the building blocks of life: amino acids, sugars, and salts. As in cremation, bones are also left behind. The liquid is disposed of through the sewer system, whereas the bones are processed in the cremulator and can be returned to the family.  Regulations of interment options vary by state. Alkaline hydrolysis is currently legal in several states, including Minnesota, Florida, and others. Our home state of Washington recently introduced legislation (SB 5001 and HB 1162) that would legalize alkaline hydrolysis as well as human composting. Human composting is similar to green burial except that decomposition occurs inside of a vessel instead of a grave. Green burial—regulated in North America by the Green Burial Council, an environmental certification organization—is an environmentally-friendly method of interment in which the unembalmed body is buried in a shallow grave inside a rapidly decomposing burial vessel, such as a shroud, cardboard box, or pine coffin. Green burial revives some traditional family-based rituals for burial and can be held in the home or at a funeral home. Since the corpse isn’t embalmed, these burials take place shortly after a death has occurred—typically within three days of the death. Bodies are kept in very early stages of decay through refrigeration and ice packs strategically placed under the body.  Conservation burial is a stricter version of green burial, requiring that families forego grave markers and non-native plants, and adhere to certain space requirements. In conservation burial, a portion of the burial fee goes toward land conservation. Hazards from green burial and conservation burial are limited, but may include extreme temperatures, uneven walking surfaces, flora, fauna, and ergonomic concerns from digging a grave and carrying a heavy load.  Everyone dies and is touched by death. We know this and plan for the future with wills and advanced directives. But how do we plan for the futures of our bodies? As Caitlin Doughty (mortician, author, and host of the YouTube channel “Ask a Mortician”) has argued, we should all have a death plan: a way for our loved ones to know what kind of ceremony and interment method we would like after we die. As industrial hygienists, we have an extra step to consider. As we devote our lives to protecting workers, we might consider the impact that our deaths have too. Perhaps it is time to ask yourself: how will I, as a future dead industrial hygienist, affect worker exposures after I’m gone?   

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